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EMERGENCY
QUICK REFERENCE
GUIDE
17/01/2019
EsA/EbA Task Force Patient Safety Sven Staender (CH) Andrew Fairley-Smith (UK) Guttorm Bratteboe (Norway) David Whitaker (UK) and Jannicke Mellin-Olsen (Norway; ESA board member) and David Borshoff (Australia; non Task Force member) Preface The ESA and EBA Helsinki Declaration on Patient Safety in Anaesthesiology1 requires to have protocols available for the management of perioperative complications. Based on the book “The Anaesthetic Crisis Manual“2 by David Borshoff and the previous ESA project “OLEH” (Online Electronic Help) by Azriel Perel, the Task Force Patient Safety has developed checklists for various emergencies that appear similar to reference guides used in aviation for in-flight emergencies. The first draft has been made available on the webpage of the European Society of Anaesthesiology at the end of the year 2012 for open feedback by every ESA member. Taking all the different and very valuable feedbacks into account, these emergency quick reference guidelines have been produced with prudence. Nevertheless, each practitioner is advised to pay careful attention when using these checklists as we do not take responsibility for the consequences out of their application. Furthermore we continue to invite everyone to give us qualified feedback for any possible improvement of these checklists in the future. These checklists are thought to be a service for the ESA and EBA members and every anaesthetist or national anaesthesia society should feel free to adopt them to their local or national practice. Our special thanks goes to Anja Sandemose (Norway), Flavia Petrini (Italy), Janusz Andres (Poland), Helmut Trimmel (Austria), Julio Cortinas (Spain), Nick Toff (UK) and Filippo Bressan (Italy) for valuable feedback and suggestions for improvement. Furthermore, various colleagues from the Task Force members and Co-authors have read and corrected the first draft. Thank you very much to all of them. Sven Staender (Chairman ESA/EBA Task Force Patient Safety) 1 Mellin-Olsen J, Staender S, Whitaker DK, Smith AF. The Helsinki Declaration on Patient Safety in Anaesthesiology. Eur J Anaesthesiol 2010 Jul;27(7):592-7. 2 Borshoff D. The Anaesthetic Crisis Manual. Cambridge University Press, Cambridge, UK 2011
Content Intraoperative Myocardial Ischaemia 1 Anaphylactic Reaction 2 Haemolytic Transfusion Reaction 3 Air Embolism 4 Laryngospasm 5 Malignant Hyperthermia 6 Newborn Life Support 7 Severe Bronchospasm 8 Local Anaesthetic Toxicity 9 Hyperkalaemia 10 Aspiration 11 Severe Bleeding 12 Increased Airway Pressure 13 Differential Diagnosis Hypocapnia / low etCO2 14 Differential Diagnosis Hypercapnia / high etCO2 15 Differential Diagnosis Bradycardia 16 Severe Bradycardia 16a Differential Diagnosis Tachycardia 17 Severe Tachycardia 17a Differential Diagnosis Hypotension 18 Left Ventricular Shock 18a Right Ventricular Shock 18b Differential Diagnosis Hypertension 19 Differential Diagnosis Desaturation / low SpO2 20
1 Intraoperative
Myocardial
Ischaemia
Sign
ECG: ST-Segment depression/elevation, new T-wave inversion, new dysrhythmias
Goal
Reduction in myocardial oxygen consumption and increase in myocardial oxygen delivery
Oxygenation
• Increase FiO2 100% (SpO2 > 94%)
• Correct anaemia.
Check Hb and consider transfusion (aim Hb 7 – 9 g/dl)
Stress Response
• Check depth of anaesthesia (avoid stimulation if possible)
• Sufficient analgesia
Myocardial Perfusion Pressure
• Increase perfusion pressure
Consider Noradrenalin 5 – 10 mcg i.v. if HR > 90/min
Consider Ephedrin 5 mg i.v. if HR < 90/min
Heart Rate
• Titrate to desired heart rate while avoiding hypotension
• Goal 60 – 80 beats/min
Consider Esmolol 0.25 - 0.5 mg/kg i.v. (± 50 – 200 mcg/kg/min)
Consider Metoprolol 2.5 mg i.v.
Contractility
• Increase contractility
Consider Dobutamin 2 – 4 mcg/kg/min
Preload
• Decrease preload
Consider sublingual Nitroglycerine (NTG) initially or
NTG infusion 0.5 - 1 mcg/kg/min
Monitor carefully
Volume status
• Avoid hypovolaemia
Consider volume load 20 ml/kg
Consider further actions
• Anticoagulation (Heparin and/or Aspirin)
• HDU/ICU admission
Multi-lead ECG monitoring, invasive monitoring, TEE, 12-lead ECG asap, repeated lab check for
troponin, CK, CK-Mb etc.
• Coronary intervention
• Intra-aortal balloon pump (IABP)2 Anaphylactic
Reaction
Sign:
• Hypotension
• Pulmonary edema
• Bronchospasm (increased insp. pressure, decreased compliance)
• Hypoxia
• Erythema / flush
• Angioedema
• Nausea / vomiting in awake patients
Call for support / inform surgeon
Stop all potential triggering substances
• e.g. drugs, colloids, blood products, latex products
Full resuscitation (start chest compression if no carotid pulse for > 10
sec)
• Adrenaline 1 mcg/kg i.v.
Start adrenaline infusion 0.1 mcg/kg/min titrated to maintain systolic blood pressure
at least 90 mmHg
• In Cardiovascular collapse:
Adrenaline 1 mg i.v. ADULT
Arenaline 10 mcg/kg i.v. CHILD
Consider Vasopressin 2 U i.v. ADULT
Consider endotracheal intubation and FiO2 100%
Increase preload
• Volume load (min. 20 ml/kg)
• Trendelenburg-Position (leg elevation, head down)
Monitoring
• Place arterial line
Take arterial blood gases
Consider further actions
• Hydrocortisone bolus i.v. or i.m.
−− > 12 years: 200mg
−− 6-12 years: 100mg
−− < 6 years: 50 mg
• H-1-blocker:
−− Clemastine 2 mg bolus i.v. or i.m.
−− Diphenhydramine bolus i.v. or i.m.
12 years: 25 – 50 mg max 100mg
• H-2-blocker: Famotidine 20 mg i.v.
• Aminophylline bolus up to 5 mg/kg i.v. or i.m.
• Take blood samples for tryptase levels
−− when patient is stabilized
−− after 2 hrs and 24 hrs
• Arrange for allergy testing after one month3 Haemolytic
Transfusion
Reaction
Signs in the patient under anaesthesia:
• Hypotension, tachycardia, circulatory instability
• Bronchospasm, wheezing, decreased pulmonary compliance,
• Hypoxia
• Urticaria, edema formation
• Bleeding from infusion sites and membranes
• Dark-coloured urine
Call for support / inform surgeon
Stop transfusion, keep iv-line open (flush with saline)
Full resuscitation (airway, breathing, circulation)
• Adrenaline 1 mcg/kg i.v.
Start adrenaline infusion 0.1 mcg/kg/min titrated to maintain systolic blood pressure
at least 90 mmHg
• In Cardiovascular collapse:
Adrenaline 1 mg i.v. ADULT
Adrenaline 10 mcg/kg i.v. CHILD
Consider endotracheal intubation and FiO2 100%
Treat bronchospasm (see reference No.13)
Volume load (min. 20 ml/kg)
Trendelenburg-Position (leg elevation, head down)
Maintain urinary output
• Use diuretics:
Mannitol 25% 0.5 - 1 g/kg i.v.
Furosemide 0.5 mg/kg i.v.
Monitoring
• Place arterial line
Take arterial blood gases
Further actions
• Consider Methylprednisolone 1- 3 mg/kg i.v.
• Take care of developing coagulopathy:
−− coagulation lab
−− consult transfusion services/laboratory
• Collect and return all transfusion products
• Check ID of patient & blood documentation
• Take fresh urine and blood samples for analysis4 Air
Embolism
Signs in the patient under Risk prone operations:
anaesthesia: • In general: surgical site higher than
• Desaturation right atrium, e.g.: head down position
• Drop of etCO2 and pelvic/lower abdomen surgery
• Hypotension, tachycardia (Gyn., Urology)
• CV collaps • Laparoscopic surgery
• Raised CVP or distended neck veins • Surgery in sitting position
• Bronchospasms, Pulm. edema
• Auscultation: ‚Mill wheel’ murmur
Call for support / inform surgeon
Prevent further entrainment of air
• Flood operative field with saline
• Compress bleeding sites
Tilt table head down and left lateral
• Caution: side supports on table?!
• In CPR: tilt table for operation side lower than level of heart (if possible)
Switch to FiO2 100% (stop N2O, if in use)
Relief pneumoperitoneum (if in use)
Cardiac support, avoid hypovolaemia
• Maintain systemic arterial pressure with vasopressors/inotropic agents
• Increase venous pressure with fluids (20 ml/kg) and vasopressors
• Use RV failure algorithm (18b)
Consider PEEP (controversial)
If central line in place: aspirate
Consider Closed Cardiac Massage
• Comment: to break up large volumes of air
• Early TEE to rule out other treatable causes of pulmonary embolism
Consider hyperbaric oxygen
• Comment: Usefull up to 6 hrs after the event
Espescially in patent foramen ovale (up to 30% of general population)5 Laryngospasm
Call for support / inform surgeon
Ask for Suxamethonium to be prepared
Ask for endotracheal tube to be prepared
Children desaturate quickly
100% Oxygen
Cease all stimulation (surgeon, nurses, orderlies etc.)
Remove any airway device and clear the airway
Jaw thrust and gentle CPAP (20 – 30 cm H2O)
• Guedel airway may be considered
• NO forced inflation attempts. May increase laryngospasm and may lead to aspiration
Consider deepening anaesthesia
• In children extreme caution! Go directly to Suxamethonium
Suxamethonium if SpO2 still decreases
• ADULT: Suxamethonium 1 mg/kg i.v.
• CHILD: Suxamethonium 1.5 mg/kg i.v.
• consider Atropine 0.02 mg/kg i.v. in advance to Suxamethonium
Intubate if necessary
Consider Atropine when going into CV collapse
• ADULT: Atropine 0.5 mg i.v.
• CHILD: Atropine 0.02 mg/kg i.v.
Stomach deflation after eventMalignant
Hyperthermia
6
Clinical Signs: Personal History:
• Hyperthermia In conjunction with congenital disease
• Hypercapnia (Strabism, Muscle disease e.g. Duchenne)
• Increase etCO2 without hypoventilation • Trigger
• Tachycardia • Volatile anaesthetics
• Sweating • Suxamethonium
• Masseter-Spasm • Muscle relaxants
• Muscle rigidity
Rapid Diagnosis
• Art. blood gases: combined respiratory
& metabolic acidosis?
• Core temperature
• Temperature of absorber cannister
(not specific)
Differential Diagnosis
• Hypercapnia, tachycardia, sweating
−− Rebreathing (Deadspace spec. in
children [long tube, extensions...])
−− Exhausted Absorber
−− Low fresh gas flow
• Metabolic acidosis
−− Hypothermia, Shock, Sepsis,
Hyperchloraemia
• Hyperthermia
−− Fever, external heating, Malignant
Neuroleptic Syndrome, MAO-
inhibitors, Atropine, Hyoscine,
Cocain
• Further differential diagnosis
−− Hypoventilation, anaphylactic
reaction, Pheochromocytoma,
thyroid storm, cerebral ischaemia,
neuromuscular disease,
Capnoperitoneum, Ecstasy
If in doubt, treat
Stop any trigger
• Switch off volatiles, switch to Propofol
• Exchange absorber
• Flush circuit with high flow oxygen
Switch to 100% oxygenMalignant
Hyperthermia
6
Increase minute ventilation
• Increase minute ventilation at least 3 times
• High fresh gas flow 100% O2
Dantrolene 2.5 – 8 (max. 10) mg/kg i.v.
• Titrate according to heart rate, rigidity and patient temperature
Cooling
• Stop cooling at < 38.5° C
Treat hyperkalaemia
• 200 ml Glucose 20% with 20 U regular Insulin over 20 min i.v.
• 10 ml Calcium chloride 10% over 10 min i.v.
• Calcium-Gluconat (100 mg/kg i.v.)
• Inhalative Beta-2 Agonist (Salbutamol)
• Consider Dialysis
Treat acidosis
• Hyperventilation
• Sodium-Bicarbonate (1 mEq/kg, max 50 – 100 mEq)
Monitoring
• Core temperature, minimum 2 peripheral lines
• Consider arterial and central line, foley catheter
• Monitor liver- and renal function
• Beware of compartment syndrome
Laboratory values
• Arterial blood gases
• Na, K
• CK
Your national MH-hotline
Tel.-number:7 Newborn
Life
Support
At all stages ask: Do you need help?
Dry the baby
Birth
Remove any wet towels and cover
Start the clock or note the time
30 sec
Assess (tone),
breathing and heart rate
If gasping or not breathing
Open the airway 6o sec
Give 5 inflation breaths
Re-assess
If no increase in heart rate look for chest movement
Acceptable*
If chest not moving pre-ductal Sp02
Recheck head position
Consider two-person airway control 2min: 6o%
or other airway manoeuvres 3min : 70%
Repeat Inflation breaths 4min : 8o%
Consider Sp02 monitoring 5min : 55%
Look for a response 10min : 90%
If no increase in heart rate
Look for chest movement
When the chest Is moving
If the heart rate is not detectable or slow (< 6o)
Start chest compressions. 3 compressions to each breath
Reassess heart rate every 30 seconds
If the heart rate is not detectable or slow(< 6o)
Consider venous access and drugs
* www.pedlatrlcs.org/cgl/dolItO.t542/pedS.2009·t5tO Copyright European Resuscitation Council - www.erc.edu - 2013/0058 Severe
Bronchospasm
Mild Bronchospasm:
• Check airway position
• Deepen anaesthesia
• Use inhalational bronchodilator therapy
Commence manual ventilation, deepen anaesthesia
Check …
• Correct airway position
• Capnography
• Airway pressure
Rule out …
• Severe allergic reaction
• Pneumothorax (previous central line placement ?)
• Left heart failure
Switch to 100% oxygen
2 - 3 puffs Salbutamol
• Use adaptor for circuit or ETT (endotracheal tube)
• Repeat if required
• Consider Salbutamol i.v. bolus (4 mcg/kg i.v. or s.c.), repeat if necessary
Ventilator settings
• Long exspiration phase
• Intermittent disconnection to avoid overinflation of the lungs and allow for CO2 escape
• Low grade PEEP
Monitor treatment response
• Capnography
• Airway pressure
Consider further actions
• Adrenaline bolus 0.1 - 1 mcg/kg i.v. (titrate)
• Magnesium 50 mg/kg over 20 min (max. 2 g) i.v.
• Aminophylline 5 - 7 mg/kg over 15 min i.v.
• Hydrocortisone 1 - 2 mg/kg i.v.
• S-Ketamine 0.5 – 1 mg/kg i.v.
• Expanded monitoring with arterial line and serial blood gases
• HDU / ICU admission9 Local
Anaesthetic
Toxicity
Signs:
• Seizures
• Slurred speech
• Numb tongue
• Tinnitus
• Metallic taste
• Higher degree AV-block during/after LA-Injection
• Hypotension
• Wide QRS complex
• Bradycardia deteriorating into PEA and asystole
Stop LA-drug administration
Commence CPR if necessary
• Small doses of epinephrine if LA toxicity is strongly suspected (10 – 100 mcg i.v.)
• Vasopressin is NOT recommended
Treat convulsions (beware of cardiovascular instability)
• Midazolam 0.05 - 0.1 mg/kg (70 kg: 5 - 10 mg)
(20 kg: 1 - 2 mg)
• Thiopentone 1 mg/kg
• Propofol 0.5 - 2 mg/kg (70 kg: 50 - 100 mg)
(20 kg: 20 - 40 mg)
Intralipid 20%
• 1.5 mg/kg bolus i.v. over 1 minute (100 ml in adults) repeat every 5 min up to a max of 3
• Followed by 15 ml/kg/h (1000 ml per h in adults)
Treat cardiac arrhythmias
• Avoid Lidocaine
• Caution with Betablockers (Myocardial depression)
• Consider Amiodarone
• Consider transcutaneous or intravenous pacemaker for symptomatic bradycardic
rhythm with pulse
Consider aditionally
• H1 blocker: Diphenhydramin 50 mg i.v.
• H2 blocker: Famotidine 20 mg i.v.
• Sodium bicarbonate to maintain pH > 7.25
• Continue CPR for a prolonged period (at least 60 min)
• ECMO10 Hyperkalaemia
EKG-signs:
• Peaked T-Waves
• Loss of P-Waves
• Prolonged PR-Intervall
• Widened QRS-complex
• Loss of R-Amplitude
• Asystoly
Stop any further K+ administration
Hyperventilation (K+ shift)
Drugs
• Adult:
−− 10 ml Calcium chloride 10% over 10 min i.v.
−− Sodium bicarbonate 8.4% 50 ml i.v.
−− 200 ml Glucose 20% with 20 U regular Insulin over 20 min i.v.
• Child:
−− Calcium chloride 10% 0.2 ml/kg over 10 min i.v.
−− Glucose 20% 0.5 g/kg with regular Insulin 0.1 U/kg i.v.
Consider further actions
• Nebulized Salbutamol
• Diuretics (Furosemide)
• Potassium-exchange resins (sodium polystyrene sulfonate)
• Hemodialysis11 Aspiration
Airway manoeuvres
• Suction oropharynx
• Tilt surgical table „head down“ position
• No cricoid pressure (Sellick) during active vomiting (risk of esophageal rupture)
• Perform laryngoscopy
• Suction pharynx
• Intubate and suction bronchial tree through endotracheal tube BEFORE first manual
ventilation
Adjust FiO2 and PEEP according to oxygenation
Suction stomach before emergence
Consider further actions
• Consider bronchoscopy
• In severe aspiration, surgery should only be performed if really urgent
• Consider HDU/ICU admission
• If patient is asymptomatic 2 hrs after event with normal saturation and chest x-ray, ICU
admission is not necessary
• NO lavage
• NO steroids
• NO antibiotics12 Severe
Bleeding
Preparation / Monitoring
• 2 large bore i.v. catheters
• Foley catheter (urine output)
• Temperature-probe
• Warm Patient actively !
• Consider arterial and central line (use ultrasound in impaired coagulation)
• Consider rapid-infusion device and cell-salvage system
• Consider anaesthesia induction with already running norepinephrine pump
Laboratory aspects
• Contact and coordinate with blood bank early
• Cross match and antibody screen (Type & screen)
• Blood count (Haemoglobin, haematocrit, thrombocytes)
• Coagulation status (incl. Fibrinogen)
• Art. blood gases (pH, Hb, ionised Ca, Lactate)
Basic therapy
• Keep normothermic (> 36 °C)
• Keep normocalcaemic (1.1 - 1.3 mmol/l, titrate Ca 1 - 2 g i.v.)
• Correct acidosis (keep normovolaemia)
• Keep haematocrit at 21% - 24%
• Aim for MAP 55 - 65 mmHg (severe head trauma MAP 80 - 90 mmHg)
Advanced therapy
• Fibrinogen 2 g up to max. 6 g Aim for: Fbg > 2 g/l
• FFP init. 15 - 20 ml/kg (~ 2 - 4 bags) Aim for: INR < 1.5
• Tranexamic acid 15 mg/kg bolus slowly i.v.
(espescially in local hyperfibrinolysis, e.g. uterine atony or abortion!)
• Thrombocytes: aim for > 50‘000/ul
(Tc > 100‘000/ul in severe head trauma)13 Increased
Airway
Pressure
1. DISTINGUISH 2. ACTIONS
Circuit Check
• Respirator settings • Muscle relaxation
• Kinked tubing • Depth of anaesthesia
• Valve failure • Capnogram
• Failure of high pressure valve −− Bronchospasm ?
• Failure of O2-flush −− Kinked endotracheal tube ?
• Spirometry
Airway −− Endobronchial intubation ?
• Laryngospasm (if not intubated) −− Kinked endotracheal tube ?
• Tube position • Tubing circuit
• Tube size −− Kinked tubing ?
• Blocked or kinked tube (patient biting −− Obstructed tubing ?
on tube)
Do
Patient • Auscultate
• Bronchospasm • Manually ventilate
• Laryngospasm (if not intubated) • Suction bronchial tree
• Pneumothorax • Flexible bronchoscopic exam
• Pneumoperitoneum • If LMA in place consider endotracheal
• Tracheal pathology tube
−− Foreign body (e.g. chewing gum)
−− Secretions If problems persist
−− Tumor • Review possible patient causes
• Chest wall rigidity • Call for assistance
• Obesity • Repeat checklist together
• Alveolar pathology
−− Oedema
−− Infection
−− ARDS
−− Contusion
−− Fibrosis
Most likely
• Insufficient relaxation
• endotracheal tube position
• Laryngospasm (if not intubated)
• Respirator settings14 Differential Diagnosis
Hypocapnia / low etCO2
No etCO2
• No etCO2 - NO VENTILATION, NO PATENT AIRWAY !!!
• Oesophageal intubation?
• Disconnection of tubing, complete failure of respirator
• Apnea
• Cardiac arrest
Diminished production of CO2
• Hypothermia
• Deep anaesthesia
• Hypothyroidism
Enhanced excretion of CO2
• (Spontaneous) hyperventilation
• Inappropriate ventilator setting
Reduced transport of CO2 in blood
• Severe hypotension
• Anaphylaxis
• Cardiac arrest
• Pulmonary embolus
Reduced transport of CO2 in lung
• Endotracheal tube obstruction
• Incorrect airway placement (endobronchial intubation)
• Laryngospasm
• Severe bronchospasm
Sampling dilution
• Disconnection of respirator
• Dilution of sampling gas with room-air
• Gas sampler placed wrong
• High fresh gas flow in circuit
Most likely
• Rule out MALPLACED AIRWAY (OESOPHAGEAL)
• Hyperventilation (too high minute ventilation)
• Bronchospasm
• Laryngospasm
• Hypotension15 Differential Diagnosis
Hypercapnia / highetCO2
Increased production of CO2
a. Exogenous:
−− CO2 insufflation (e.g. laparoscopy)
−− Bicarbonate administration
−− Re-breathing (valves, Soda lime, fresh gas-flow)
b. Endogenous:
−− Painful stimulus
−− Increased body temperature
−− Reperfusion after Tourniquet
−− Sepsis, Malignant Hyperthermia
−− Thyroid storm, Malignant Neuroleptic Syndrome
Reduced excretion of CO2
a. Lungs:
−− Hypoventilation (spont. or respirator settings)
−− Bronchospasm, asthma
−− COPD (chronic airway disease)
b. Breathing circuit:
−− Increased dead space
−− Inadequate fresh gas flow
−− Valve malfunction
−− Incorrect respirator settings
Most likely
• Hypoventilation (spontaneous or respirator settings)
• Exhausted soda lime
• Fresh gas flow setting16 Differential
Diagnosis
Bradycardia
Primary causes
• Atrioventricular block
• Pacemaker malfunction
• Cardiomyopathy
• Sick sinus syndrome
• Myocarditis
• Pericarditis
• Valvular heart disease
• Pumonary Hypertension
Secondary causes
• Elektrolyte abnormalities
• Antiarrhytmic medication
• Hypothyroidism
• Hypothermia
• Hypervagal
• Increased intracranial pressure
• Temponade
• Tension pneumothorax
Anaesthetic causes
• Hypoxia
• Volatile agent side effects
• Muscle relaxant side effects
• Narcotic
• Anticholinesterase drugs
• High spinal/ epidural anaesthesia
• Local anaesthetic toxicity
• Hyper- Hypokalaemia
• Vasopressor reflex
• Auto-PEEP
• Malignant Hyperthermia
Most likely
• Drug related
• Hypervagal
• Spinal anaesthesia
• Fitness16A Severe
Bradycardia
Check / rule out
• Pulseoxymetry, Oxymeter, Skin and field blood colour: rule out hypoxia
• Hypovolaemia
• Auto-PEEP
• Gas/air embolism? Thrombo/fat embolism?
• High spinal/epidural
• Tension pneumothorax
• Tamponade
• Other primary, secondary or anaesthetic causes (see Reference Guide 16)
In severe hypotension, poor perfusion, or low etCO2
• Start CPR
• Improve oxygenation
• Assist ventilation (avoid hyperventilation)
• Volume load (20 ml/kg), repeat if necessary
• Treat potential underlying cause (see check / rule out list above)
• Consider Atropine 0.5 mg i.v. (may repeat up to 3 mg in total)
• Consider Epinephrine 10 to 100 mcg i.v. (may repeat while awaiting pacer)
−− Consider Epinephrine infusion (0.05 – 0.1 mcg/kg/min)
−− Consider Dopamine infusion (2 – 10 mcg/kg/min)
• Consider Isoproterenol 4 mcg i.v. (may repeat while awaiting pacer)
• Consider arterial- and central venous line
If the above is ineffective (use without delay in high-degree block)
• Transcutaneous pacing
• Esophageal pacing
• Transvenous pacing
Consider expert consultation
Acc: Moitra V.K. et al: Can J Anesth/J Can Anesth (2012) 59:586–60317 Differential
Diagnosis
Tachycardia
Primary causes
• Cardiomyopathy
• Sick sinus syndrome
• Accessory conduction pathways (Re-entry)
• Myocarditis
• Pericarditis
• Valvular disease
• Congential heart disease
Secondary causes
• Hypovolaemia
• Anaesthetic depth
• Drugs
• Anxiety
• Pain
• Electrolyte abnormalities
• Cardiac tamponade
• Sepsis
• Thyreotoxicosis
• Lung disease
• Malignant hyperthermia
Most likely
• Anaesthetic depth and surgical stimulation
• Anxiety and pain
• Hypovolaemia17A Severe
Tachycardia
Check / rule out
• Light anaesthesia
• Hypovolaemia
• Auto-PEEP
• Early hypoxia or hypercapnea
• Other primary or secondary causes (see Reference Guide 17)
In severe hypotension or poor perfusion
• Consider synchronized cardioversion
Narrow QRS
• Rhythm regular
−− Consider vagal maneuvers
−− Consider Adenosine 6 mg i.v. push
if no response give Adenosine 12 mg i.v. push
−− If still no conversion:
consider beta blocker (e.g. Metoprolol 2.5 mg i.v.) or Ca channel blocker
• Rhythm irregular
−− Low ejection fraction (EF) or severe hypotension
consider synchronized cardioversion
consider load Amiodarone 150 mg i.v. over 10 min
−− Normal EF or acceptable blood pressure
consider beta blocker (e.g. Metoprolol 2.5 mg i.v.) or Ca channel blocker
Wide QRS
• Rhythm regular
−− If ventricular tachycardia or uncertain rhythm
consider load Amiodarone 150 mg i.v. over 10 min and Calcium chloride 1 g i.v.
if no Amiodarone available: Lidocaine 1 – 1.5 mg/kg i.v
• Rhythm irregular
−− If Torsade-de-Pointes
Consider Magnesium Sulfate 2 g i.v. over 5 min (consider repeat)
−− If pre-excited atrial fibrillation
consider load Amiodarone 150 mg i.v. over 10 min
Consider expert consultation
Acc: Moitra V.K. et al: Can J Anesth/J Can Anesth (2012) 59:586–60318 Differential
Diagnosis
Hypotension
Preload Reduction
• Blood loss
• Hypovolaemia
• Decreased venous return (caval vein?)
• Elevated intrathoracic pressure
• Cardiac Tamponade
• Embolism
Reduced Contractility
• Drugs (including volatile agents)
• Ischaemic heart disease
• Cardiomyopathy
• Myocarditis
• Arrhythmia
• Valvular heart disease
Reduced Systemic Vascular Resistance
• Volatile anaesthetics
• Narcotics
• Vasodilators
• Antihypertensive drugs
• Regional blockade (spinal/epidural)
• Sepsis
• Release of tourniquet
• Anaphylaxis
• Addison’s disease
• Thyroid disease
Most likely
• Depth of anaesthesia and volatile anaesthetics
• Narcotics
• Regional blockade (spinal/epidural)
• Hypovolaemia
• Transducer height (invasive monitoring)18A Left
ventricular
Shock
Hypotensive ? N SVR > 1600 Afterload Reduction
Perform Echo/ or narrow pulse Fenoldopam
TEE in intubated patient pressure Nitroprusside
Nesiritide, ACEi
Y
Decrease
PEEP Y pRBC
CVP < 12 mmHg
Hct < 27 -32 ?
Or SPV/PPV > 12%
Check CVP N Plasma
And Expander
SPV or PPV
CVP > 22
Low SvO2 or ScvO2
SPV/PPV > 15% R/O tamponade
R/O tension PTX
CVP 12 – 22
SPV/PPV < 12%
SVR < 800 Vasopressin
or Norepinephrine Epi ±
wide pulse pressure Dobutamine
Phenylephrine
Check SVR and pulse MAINTAIN SVR > 800
pressure
SVR > 1000 Dobutamine
or Epinephrine
narrow pulse pressure IABP
VAD
SPV = systolic pressure variation
SVR = systemic vascular resistance in dyne sec-1cm5m2
PTX = pneumothorax
IABP = intraortic balloon pump
VAD = ventricular assist device
PEEP = positive end-expiratory pressure
ACEi = angiotensin-converting enzyme inhibitor
Moitra V.K. et al: Can J Anesth/J Can Anesth (2012) 59:586–603
Can J Anesth/J Can Anesth: „Open Access This article is distributed under the terms of the Creative Commons Attribution
License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source
are credited.“18B Right
ventricular
Shock
Hypotensive ?
Perform Echo/
TEE in intubated patient
Y
Give O2
Decrease PEEP
Y pRBC
Hypovolemic?
Fluid Responsive? Hct < 27 – 32?
e.g. CVP < 12 – 16? Y
Plasma
N
N Expanders
CVP > 20
SVO2 or ScvO2 < 65%
R/O tamponade
R/O tension PTX
Known or Suspected
increased PVR?
Decreased coronary Diminished
perfusion? RV contractility
Y
Give O2 Y Y
Consider Milrinone ±
Vasopressin, iNO Phenylephrine Dobutamine
Norepinephrine Milrinone
Vasopressin Epinephrine
Note: these medications
may increase PVR
TEE = Trans esophageal echo
CVP = central venous pressure
pRBC = packed red blood cells
SVO2 = systemic oxygen consumption
ScvO2 = central venous oxygen saturation
PEEP = positive end-expiratory pressure
iNO = inhaled Nitric oxyde
PVR: pulmonary vascular resistance
Moitra V.K. et al: Can J Anesth/J Can Anesth (2012) 59:586–603
Can J Anesth/J Can Anesth: „Open Access This article is distributed under the terms of the Creative Commons Attribution
License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source
are credited.“19 Differential
Diagnosis
Hypertension
Anaesthesia related causes
• Too light anaesthesia
• Pain
• Hypoxia
• Hypercapnia
• Malignant hyperthermia
• Drugs (Cocain)
• Transducer height (invasive monitoring)
Surgery related causes
• Tourniquet
• Aortic clamping
• Carotid endarterectomy
• Baroreceptor stimulation
• Pneumoperitoneum
Patient related causes
• Essential hypertension
• Rebound-Hypertension (sudden stop betablocker)
• Full bladder
• Pre-eclampsia
• Renal disease
• Phaeochromocytoma
• Thyroid storm
• Raised intracranial pressure
Most likely
• Intubation and emergence from anaesthesia
• Inadequate anaesthesia, analgesia
• Pneumoperitoneum
• Drugs
• Essential hypertension20 Differential
Diagnosis
Desaturation
Airway
• Endobronchial intubation
• Airway obstruction
• One lung ventilation
• Laryngospasm
• Aspiration
Breathing / Ventilator
• Low fresh gas flow
• Bronchospasm
• Respirator malfunction/setting
• Circuit obstruction/disconnection
• Pulmonary oedema
• Contusion
• Atelectasis
• Pneumothorax
• Pneumonia
• Sepsis / ARDS
Circulation
• Cardiac arrest
• Cardiac failure
• Anaphylaxis
• Pulmonary embolism
• Hypothermia
• Poor peripheral circulation
• Methaemoglobinaemia (Prilocain, Lidocain, Benzocain)
Most likely
• Probe displacement
• Apnea and hypoventilation
• Tube position
• Laryngospasm
• BronchospasmYou can also read
